TEST BANK FOR ATI PN Adult Medical Surgical Nursing Edition 12.0 Content Mastery Series Review Module UNITS 1-14
UNIT 1: FOUNDATIONS OF NURSING CARE 20 Practice Questions with Rationales
1. Which action best prevents the spread of infection in the clinical setting? A. Wearing gloves for all client contact B. Performing hand hygiene before and after client contact C. Cleaning equipment once per shift D. Wearing a mask when entering all rooms ✅Correct Answer: B Rationale: Hand hygiene is the single most effective method to prevent transmission of microorganisms. Gloves do not replace hand hygiene.
2. A nurse is assisting a client to move up in bed. Which action reduces the risk of injury to the nurse? A. Keeping feet close together B. Bending at the waist C. Using leg muscles to lift D. Twisting while lifting
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✅Correct Answer: C Rationale: Using leg muscles and keeping the back straight helps prevent musculoskeletal injury.
3. A client is at risk for aspiration. Which position is most appropriate during meals? A. Supine B. Side-lying C. Semi-Fowler’s D. High-Fowler’s ✅Correct Answer: D Rationale: High-Fowler’s position (upright) reduces the risk of aspiration during eating.
4. Which vital sign should be reported immediately? A. Temperature 37.2°C (99°F) B. Pulse 88/min C. Respirations 10/min D. Blood pressure 120/78 mm Hg ✅Correct Answer: C Rationale: A respiratory rate of 10/min is below normal and may indicate respiratory depression.
5. Which client is at highest risk for developing a pressure injury? A. A client who ambulates with assistance B. A client who is incontinent and immobile C. A client with controlled diabetes D. A client receiving oral antibiotics ✅Correct Answer: B Rationale: Immobility and moisture from incontinence significantly increase pressure injury risk.
6. When should a nurse use sterile gloves? Downloaded from Scholarfriends.com
A. Administering oral medication B. Performing catheter insertion C. Assisting with feeding D. Taking vital signs ✅Correct Answer: B Rationale: Sterile gloves are required for invasive procedures such as catheter insertion.
7. Which action demonstrates correct use of Standard Precautions? A. Wearing gloves only if blood is visible B. Using a mask for all client care C. Treating all body fluids as potentially infectious D. Isolating all clients with fever ✅Correct Answer: C Rationale: Standard Precautions assume all blood and body fluids may be infectious.
8. A nurse is documenting care provided. Which entry is appropriate? A. ―Client acted confused and difficult‖ B. ―Client appears to be in pain‖ C. ―Client reports pain level 7/10‖ D. ―Client was uncooperative today‖ ✅Correct Answer: C Rationale: Documentation should be objective and include the client’s exact statements when possible.
9. Which food selection is best for a client on a clear liquid diet? A. Applesauce B. Milk C. Chicken broth D. Cream soup ✅Correct Answer: C Rationale: Clear liquids include broth, gelatin, and clear juices.
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10. A nurse is assisting a client to ambulate for the first time after surgery. What is the priority action? A. Encourage fast walking B. Check blood pressure before ambulation C. Ensure the client wears shoes D. Walk the client to the hallway ✅Correct Answer: B Rationale: Assessing blood pressure helps identify orthostatic hypotension and prevents falls.
11. Which finding indicates dehydration? A. Moist mucous membranes B. Urine specific gravity 1.030 C. Bounding pulse D. Decreased hematocrit ✅Correct Answer: B Rationale: Elevated urine specific gravity indicates concentrated urine, a sign of dehydration.
12. Which client statement shows understanding of fall prevention? A. ―I will get up without help if I feel okay.‖ B. ―I will wear non-skid footwear when walking.‖ C. ―I don’t need the call light.‖ D. ―I will sit on the edge of the bed before sleeping.‖ ✅Correct Answer: B Rationale: Non-skid footwear reduces the risk of slipping and falls.
13. What is the priority nursing action for a client with a fever? A. Provide extra blankets B. Encourage fluid intake C. Limit oral intake D. Apply ice packs ✅Correct Answer: B Rationale: Fever increases fluid loss; encouraging fluids helps prevent dehydration. Downloaded from Scholarfriends.com
14. Which action by the nurse protects client confidentiality? A. Discussing care with family in the hallway B. Logging off the computer after documentation C. Sharing information with another client D. Leaving charts open at the nurses’ station ✅Correct Answer: B Rationale: Logging off prevents unauthorized access to private health information.
15. A nurse identifies a medication error after administration. What is the priority action? A. Document the error B. Complete an incident report C. Assess the client D. Notify the charge nurse ✅Correct Answer: C Rationale: Client safety comes first; assess for adverse effects before reporting.
16. Which task can the nurse safely delegate to unlicensed assistive personnel (UAP)? A. Assessing pain level B. Teaching incentive spirometer use C. Measuring intake and output D. Administering medications ✅Correct Answer: C Rationale: Measuring I&O is a routine, non-assessment task appropriate for UAP.
17. Which sign indicates adequate oxygenation? A. Cyanotic nail beds B. Restlessness C. Oxygen saturation 96% D. Increased heart rate Downloaded from Scholarfriends.com